FORM – 1

(See Rule 6(2)

Application cum declaration as to the fitness
1 Name of the Applicant
2 Son/Wife/Daughterof
3 Parmanent Address
4 Temporary Address
5 Official Address (if any)
6 a) Date of Birth
b) Age on date of application
7 Identification Marks 1)
2)

Declaration:

a) Do you suffer or from sudden attacks of consciousness or Giddiness from Yes No

any cause?

b) Are you able to distinguish with each eye (or if any have a driving licence
to drive motor vehicle for a period of not less than five years and if you Yes No

have lost the sight of one eye after said period of five years and it the
applicant is driving a light motor vehicle other than the a transport vehicle
fitted with an outside mirror on the steering wheel side) or with one eye at
distance of 25 meter in good day light (with glasses if whom) a motor car
number plate?)

c) Have you lost either hand or foot or are you suffering from any defect or Yes No

Muscular pain of either arm leg?

d) Can you readily distinguish the pigmentary colors Red and Green? Yes No

e) Do you suffer from night blindness. Yes No

f) Are you so deaf as be unable to hear 9and if application is driving of a Yes No

light motor vehicle with or without hearing aid) the ordinary sound?

g) Do you suffer any other disease or disability to cause you a driving of a Yes No
motor vehicle to be a source of danger to the public? If so give details.

I hereby declare that the best of my knowledge and belief the particulars given above and the
declaration made herein are true.

Signature or thumb impression

Of the applicant

Note: An applicant who answer Yes to any of the question (a), (c), (e), (f) and (g) and No. to either of
the questions (b) and 9d) should smplify his answer with full particulars and may be required. To give
further information relating thereto.